Defined by the Centers for Medicare and Medicaid Services, diagnosis-related groups or DRGs are categories of clinical conditions that occur together. For example, if thrush is diagnosed as a result of HIV infection, both pathologies would be found in one DRG.
If a medical complication or surgical procedure is a result of another diagnosis, the cost of treating the secondary complication or procedure varies greatly from when the condition exists alone or as the result of a different anomaly. This is why a medical biller's job of assigning accurate DRGs is essential to the reimbursement of Medicare providers.
The following medical record information is used to determine the assignment of DRGs: gender, age, principal diagnosis, secondary diagnoses, surgeries and patient state at discharge.
Top Five Diagnosis-related Groups
Five of the top 10 diagnosis-related groups reported by CMS include heart failure and shock, angina pectoris, psychoses, chronic obstructive pulmonary disease, and cerebrovascular disorders.